A nurse is teaching a newly licensed nurse about appropriate actions to take when a client threatens to harm a specific individual. Which of the following statements by the newly licensed nurse indicates understanding?
“I need to make sure that the potential victim is warned."
"I need to keep the information confidential due to the client's right to privacy."
“I can only discuss the client's threats with a court order."
"I should verbally report this information to the psychiatrist."
The Correct Answer is A
A. "I need to make sure that the potential victim is warned."
Explanation: Correct Answer. When a client threatens to harm a specific individual, it's important to take steps to ensure the safety of both the client and the potential victim. Warning the potential victim or taking appropriate measures to protect them is an important action to take.
B. "I need to keep the information confidential due to the client's right to privacy."
Explanation: While respecting a client's right to privacy is important, when there's a threat of harm to an individual, it becomes a matter of safety that takes precedence over confidentiality.
C. "I can only discuss the client's threats with a court order."
Explanation: This statement is incorrect. When there's a credible threat to harm an individual, waiting for a court order is not an appropriate or timely response. Immediate actions should be taken to ensure safety.
D. "I should verbally report this information to the psychiatrist."
Explanation: While involving the psychiatrist is important for the client's overall care, it's essential to take more immediate steps to ensure the safety of the potential victim, such as notifying the appropriate authorities or taking appropriate precautions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
A. Female gender: Incorrect
While the risk of attempted suicide is generally higher in females, completed suicide rates are higher in males. Therefore, being female is not typically considered a primary risk factor for suicide,though it's important to note that both genders require attention for prevention.
B. Currently married: Incorrect
Being married is generally considered a protective factor against suicide. Social support and close relationships tend to reduce the risk of suicidal behavior.
C. Age greater than 45 years old: correct
Suicide risk tends to increase with age, particularly for men. Individuals over 45, especially those facing chronic illness, social isolation, or significant life changes, are at higher risk.
D. Substance use disorder: Correct
Substance use disorder is a significant risk factor for suicide. Substance abuse can contribute to feelings of hopelessness and despair, impair judgment, and lower inhibitions, increasing the likelihood of suicidal behavior.
E. Schizophrenia: Correct
Schizophrenia is a mental disorder associated with an increased risk of suicide. The symptoms of schizophrenia, such as hallucinations, delusions, and feelings of isolation, can contribute to severe distress and increase the risk of suicidal ideation and behaviors.

Correct Answer is D
Explanation
A. "Tell me who you think doesn't care about you."
Explanation: This response might come across as confrontational or defensive, which could discourage the client from opening up further. It's important to offer support and understanding rather than putting the client on the spot.
B. "Of course people care. Your family comes to visit every day."
Explanation: While it's true that the client's family visits, depression often distorts perception and emotions. Telling the client that people care might not be fully effective in addressing their feelings of worthlessness.
C. "Why do you feel that way?"
Explanation: This response opens the door for the client to express their emotions and thoughts. It encourages further conversation and helps the nurse understand the underlying causes of the client's feelings.
D. "I care about you, and I am concerned that you feel so sad."
Explanation: Correct Answer. This response shows empathy and genuine concern for the client's well-being. It acknowledges the client's emotions, offers support, and validates their feelings.
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